Pro-yellow laser therapy in vascular and non-vascular skin disorders: A narrative review

Facial telangiectasia

Facial telangiectasias are superficial cutaneous vessels that can be observed with the naked eye.³ These enlarged capillaries, arterioles, or venules range in diameter from 0.1 to 1.0 mm. Arteriolar telangiectasias have a small diameter, are bright red, and do not protrude above the skin’s surface. Telangiectatic lesions originating from venules are larger, bluish, often extend above the skin surface, and are more prominent compared to arteriolar lesions. When telangiectasia develops in the capillary ring, the lesions are usually small and red at first. Still, over time, venous reflux brought about by increased hydrostatic pressure causes the lesions to enlarge and turn purple or blue.⁴

Five articles, encompassing a total of 137 patients treated with PYL for facial telangiectasia between 2018 and 2022, were identified.

An analysis of 40 patients with facial erythema, facial telangiectasia, and erythematotelangiectatic rosacea reported an improvement of 80–100%. Eleven of them had facial erythema, and nine of them had both facial telangiectasia and facial erythema.¹ With the exception of a slight erythema that persisted for about 60 min following the procedure, there were no adverse reactions, such as the development of atrophic scars or post-inflammatory hyper- or hypopigmentation.¹ Mohamed et al.,⁵ examined the PYL in 95 patients with papulopustular rosacea, port-wine stain nevus, facial erythema, and facial telangiectasia. More than 50% of the patients showed significant improvement. Sixteen of them were patients with facial telangiectasia. An average of 3.63 sessions was required. Adverse events were skin irritability and temporary erythema that went away quickly.⁵

Turkmen et al., evaluated the efficiency of single-session PYL treatment in 41 patients. Thirty-seven of them had facial telangiectasia.⁶ They observed good or better improvement in 51.4% of facial telangiectasia patients 4 weeks later. No serious or long-lasting side effects were reported.⁶ In the study of Sarac and Onder, 74 patients with facial telangiectasia and other vascular lesions were treated by PYL. Thirty-seven of these patients had facial telangiectasia and received an average of 1.83 treatment sessions. They reported excellent improvement in 26 cases (70.3%) and very good improvement in 11 cases (29.7%). The only adverse event noted was mild erythema, which disappeared after 12–24 h.⁷

Ataseven et al., examined PYL therapy in 98 patients with vascular lesions, including facial telangiectasia, erythematotelangiectatic rosacea, facial erythema, and facial erythema combined with facial telangiectasis.⁸ Twenty-seven patients with facial telangiectasia received an average of 1.7 treatment sessions. The mean success rate was 83.3%, with excellent improvement in 14 cases (51.9%), and good or very good one in 13 cases (48.1%). The unwanted side effects were temporal erythema, mild irritation on dry-sensitive skin, mild pain at high j, but no permanent, irreversible side effects.⁸ Results of studies on facial telangiectasia treatment are summarized in Table 1. Some clinical examples before and after laser treatment are shown in Figures 1-3.

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Figure 1:

Facial telangiectasia 1: (a) 38-year-old male patient, before and (b) immediately after treatment with 26 J/cm² scanner mode.

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Figure 2:

(a) Facial telangiectasia. 64-year-old male patient, (b) 1^st month after treatment with 28 J/cm² pen mode.

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Figure 3:

Facial telangiectasia. (a) 44-year-old male patient, (b) immediately after treatment with 28 J/cm² scanner mode (right).

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Poikiloderma of civatte (PC)

Poikiloderma includes reticular-patterned superficial atrophy, linear telangiectasia, and mottled hyperpigmentation or depigmentation.⁹ PC, first described in 1923, is an acquired reticular pigmented poikiloderma of the face and neck that is relatively common.¹⁰

The literature search revealed two articles published between 2020 and 2021, including a total of 15 patients undergoing PYL therapy for PC.

Temiz et al.,¹¹ used PYL treatment at 4-week intervals in a Fitzpatrick III skin type patient with PC. Lesions significantly receded after four laser sessions, particularly the vascular component. There were no signs of a recurrence during the patient’s 16-month follow-up. The only adverse events were temporary erythema and mild pain during the laser treatment.¹¹

Sarac et al.,¹² used PYL treatment in 14 patients with PC. They reported minor improvement in 6 (42.8%) patients (ranging from 1 to 25%) and moderate improvement in 8 (57.2%) patients (ranging from 26% to 50%) after the first treatment session. The most common adverse event was mild erythema lasting 60 min after treatment without causing interruption.¹²

Facial erythema

The efficacy of PYL treatment was examined in three studies conducted between 2018 and 2022. A total of 44 patients with facial erythema were included.

Mohamed et al.,⁵ used PYL laser therapy in 22 patients with facial erythema. The mean age was 22.3 ± 3.04 years. Among the patients, 1 (4.6%) had skin type Fitzpatrick II, 5 (22.7%) had skin type Fitzpatrick III, and 16 had skin type Fitzpatrick IV (72.7%). The mean number of sessions was 1.8 ± 0.85. They observed excellent improvement in 14 patients (63.6%), very good improvement in 5 patients (22.7%), and good improvement in 3 patients (13.6%). The only side effects were temporary erythema that subsided 2 days after the session and irritation during the session.⁵

Kapicioglu et al.,¹ examined PYL therapy in 13 patients with facial erythema. The success rate was 95.38 ± 1.53% (standard deviation) sessions on average. Their study found a higher success rate with fewer sessions when treating facial erythema compared to facial telangiectasia. The major adverse reaction was a mild rash lasting about 60 min after the sessions.¹

Ataseven et al.,⁸ examined PYL therapy in nine patients with facial erythema. The mean age was 30.3 ± 9.1 years. Skin types were Fitzpatrick II in 6 patients (66.9%) and Fitzpatrick III in 3 (33.3%). They used 2 ± 0.7 sessions on average. The mean success rate for facial erythema was 68.3%.⁸ Results of laser treatment are illustrated in Figure 4.

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Figure 4:

Facial erythema. (a) 39-year-old female patient, (b) after four sessions of treatment with 22-24-26-28 J/cm² scanner mode, session intervals are 1 month.

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Keratosis pilaris rubra (KPR)

KPR is a clinical variant of keratosis pilaris (KP), which is usually distinguished by the presence of numerous “grain-like” follicular papules against a background of confluent erythema. The face, trunk, and outer upper extremities are the typical locations. It can be distinguished from KP atrophicans by its absence of atrophy and from erythromelanosis follicularis faciei et colli by its erythema.¹³

In the study Temiz et al.,¹⁴ PYL treatment was used at 4-week intervals in four patients with KPR. Their mean age was 19.5 years. Two patients (50%) had Fitzpatrick II skin type, and 2 (50%) had Fitzpatrick IV skin type. They used four sessions for each patient. While the rate of erythema clearance was 75% in three patients, it was 50% in one patient. They experienced only mild irritation and pain, but no permanent or irreversible side effects. No recurrence was observed during ≥3 month follow-up.¹⁴

Port-wine stains (PWS)

PWS are birthmarks resulting from malformations of the cutaneous capillaries and venules. They comprise a network of enlarged blood vessels in the dermis. Later vascular nodules develop, classified as acral arteriovenous tumors.¹⁵ Four articles investigating PYL therapy in PWS were reviewed. They included 73 patients, published between 2019 and 2022.

Mohamed et al.,⁵ evaluated PYL treatment in 37 patients with PWS. The mean age was 19.3 ± 7.72 years. Skin phototypes were Fitzpatrick I in 1 patient (2.7%), Fitzpatrick II in 2 patients (5.4%), and Fitzpatrick IV in 34 patients (91.9%). The patients received 7.76 ± 2.28 sessions on average. The authors observed excellent improvement in 10 cases (27.02%), very good in 14 cases (37.8%), good in 7 cases (18.9%), and poor improvement in 6 cases (16.2%). They found no association of treatment response to the patient’s age, sex, PWS duration, skin phototypes, or PWS location.⁵

Sarac and Kapicioglu evaluated PYL treatment at 4-week intervals in 26 patients with PWS. The mean age was 24.7 ± 11.8 years. Skin phototype was Fitzpatrick II in 14 patients (53.8%), Fitzpatrick III in 11 patients (42.3%), and Fitzpatrick IV in 1 patient (3.8%). The lesional skin was dry in 12 patients (46.2%) and oily in 14 patients (53.8%). The face and neck region hosted all lesions. On average, a PWS-regression of 68.8 ± 13.9% was achieved (minimum 40%, maximum 90%). Between one and ten sessions were necessary (5.23 ± 2.7 on average).¹⁶

Sarac and Onder examined PYL treatment at 4-week intervals in six patients with PWS. Patients underwent 3.33 sessions on average. The authors reported excellent improvement in 1 patient (16.7%) and very good improvement in 5 patients (83.3%).⁷

Ataseven et al.,⁸ reported PYL treatment in four patients with PWS. The mean age was 16.5 ± 2 years. One of the patients had Fitzpatrick II, two Fitzpatrick III, and one Fitzpatrick IV skin phototype. On average, 3.75 ± 0.5 sessions were performed. One patient achieved a very good score, and three showed good improvement. The mean success rate was 65%.⁸

Clinical examples of laser treatment are illustrated by Figures 5 and 6.

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Figure 5:

Port-wine stain. (a) 46-year-old female patient, (b) after six laser sessions with 20-22-24-26-28-30 J/cm² scanner mode, session intervals are 1 month.

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Figure 6:

Port-wine stain. (a) 43-year-old female patient, (b) after three laser sessions with 24-26-28 J/cm² scanner mode, session intervals are one month.

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Venous lakes (VLs)

VLs are defined as venous cutaneous vascular ectasias of venules in the upper dermis.¹⁷ These papulonodular lesions are soft, dark blue, and slightly elevated. VLs are seen more common with age. Lower lips are the most commonly site.¹⁸

Temiz et al.,¹⁹ applied two sessions of PYL treatment at a 4-week interval to treat a VL of the lower lip of a 45-year-old female with Fitzpatrick III skin phototype. Significant regression was observed after treatment, and no adverse events occurred in the treatment area other than minimal edema and rash.¹⁹

Sarac and Onder used PYL treatment on six VL patients, 1.5 sessions on average. They observed excellent improvement in 3 patients (50%) and very good improvement in 3 patients (50%). Neither bullae nor hyperpigmentation or scar formation were observed.⁷

Spider angioma

A central arteriole with outward-facing thin-walled vessels makes up a spider angioma. The name is derived from the central ascending arteriole, and the radial fine vessels resemble a spider’s net, respectively. The diameter can range from a pinhead up to 2 cm.²⁰

We found two articles investigating PYL treatment in 15 patients with spider angioma. Sarac and Onder applied PYL treatment to 6 spider angioma patients at 4-week intervals. There were 1.16 sessions on average. They observed excellent improvement in all cases. Transient erythema that vanished within 24–48 h of the session was the only adverse effect noted.⁷

Ataseven et al.⁸ used PYL therapy in nine patients with spider angioma (mean age 27.2 ± 17 years). One (11.1%) of the patients had a Fitzpatrick II skin phototype, and 8 (88.9%) had a Fitzpatrick III skin phototype. The mean number of sessions was 1.4 ± 0.7. They observed excellent improvement in all patients, and the mean success rate was 94.4%.⁸

Cherry angioma

Cherry angiomas are multiple, asymptomatic lesions that are relatively common and tend to appear on the arms and trunk more frequently as people age. They represent small (0.1–0.5 cm in diameter) smooth, dome-shaped, soft, compressible papules ranging in color from bright red to violet. When compressed, they turn white and may bleed profusely.²¹

Sarac and Onder reported PYL treatment in four cases of cherry angioma in Turkish patients. A single treatment session was sufficient for all patients. The authors observed excellent improvement in all patients. Neither bullae nor hyperpigmentation nor scar formation was observed.⁷

Hemangiomas

Hemangiomas 12% of all infants are the most prevalent benign soft-tissue tumor in infancy and childhood. They are more frequently found in twins, premature infants, girls, Caucasians, and are typically born to mothers who are older than average.²²

Ataseven et al.⁸ reported on PYL treatment in four hemangioma patients, with an average age of 32.7 ± 13.7 years. Two patients (50%) had Fitzpatrick II skin type, and the other two patients (50%) had Fitzpatrick III skin type. A mean number of 3.2 ± 0.9 sessions was performed. One (25%) patient showed an excellent improvement, and 3 (75%) showed very good improvement. The mean success rate was 80%.⁸

Figure 7 shows an example of laser treatment of a capillary hemangioma on the nose.

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Figure 7:

Facial erythema and capillary hemangioma on the nostril. (a) 28-year-old male patient, (b) after 1 month after treatment with 30 J/cm² pen mode.

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Genital angiokeratoma

Genital angiokeratomas (Fordyce) are tiny red or purple papules caused by ectasia of superficial vessels and hyperkeratotic epidermis.^23,24

A single study reported PYL treatment in two patients with genital angiokeratoma. Their Fitzpatrick skin type was not specified. An excellent improvement was noted in both patients, with a 100% success rate. The average number of laser sessions was 2.⁸

Rosacea

Rosacea is a chronic inflammatory skin disease of the central face. Cutaneous symptoms include edema, flushing, persistent erythema, papulopustules, telangiectasia, and phymas.²⁵ There are four disease subtypes of rosacea: Papulopustular, phymatous, erythematotelangiectatic, and ocular. A single patient may be affected by more than one subtype.²⁶

We identified two studies, published between 2020 and 2021, that described PYL treatment for rosacea, involving 59 patients.

Temiz et al.²⁷, applied PYL treatment to 34 patients (mean age: 42.8 ± 8.8 years). Skin types were classified as Fitzpatrick II in 41.2% (14 patients) and Fitzpatrick III in 58.8% (20 patients). The success rate of a single-session PYL therapy for erythema was 73.2 ± 10.4% 4 weeks after laser application. While the density of Demodex mites was 18.1 ± 10.7 cm² before treatment, it was 10.2 ± 7.9 cm² 4 weeks after treatment. No significant correlation was found between the regression of Demodex density and the regression of erythema.²⁷

Altunisik et al.,²⁸ analyzed the PYL treatment in 25 patients. The mean age of the patients was 41.4 ± 9.3 years. While the mean Demodex count was 3.9 ± 5.0/cm² before treatment, it decreased to 2.6 ± 4.9/cm² after treatment, but this difference was not statistically significant. The Demodex count in two patients who were previously negative was found to be positive after laser treatment, but no clinical exacerbation was observed.²⁸

Mohamed et al.,⁵ investigated the PYL therapy in 20 patients with papulopustular rosacea. The mean age of the patients was 24.7 ± 8.01. Two patients had skin type Fitzpatrick II (10%), 6 had Fitzpatrick III (30%), and 12 had Fitzpatrick IV (60%). On average, 3.1 ± 1.8 laser sessions were performed. The authors observed excellent (≥75%) improvement in 8 (40%) patients, very good (≥50–74%) in 4 (20%), good (≥25–49%) in 6 (30%), and poor (<25%) in 6 (10%).⁵

Kapicioglu et al.,¹ reported on PYL treatment in seven patients with erythematotelangiectatic rosacea. While the success rate was 91.42%, the average number of sessions was 3.14. They experienced either mild or no side effects.¹

Sarac and Onder investigated PYL therapy in 13 patients with erythematotelangiectatic rosacea. They saw excellent improvement in 6 patients (46.2%), very good improvement in 6 patients (46.2%), and good improvement in 1 patient (7.6%). On average, they used 2.23 laser sessions.⁷

Ataseven et al.,⁸ examined PYL treatment in 31 patients with erythematotelangiectatic rosacea. The mean age was 31.2 ± 15.4. Skin types were Fitzpatrick II in 12 (38.7%), Fitzpatrick III (58.1%) in 18, and Fitzpatrick IV (3.2%) in 1 patient. The average number of sessions was 2.7 ± 0.9. Excellent and very good outcome was noted in 83.9%, while the success rate was 74.8%. Persistent irreversible adverse effects did not emerge.⁸

Vulvar syringoma

Syringomas are benign sweat gland tumors that most frequently develop in the periorbital region. Their potential involvement in the vulvar skin, where they may significantly increase pruritus, is less frequent and underappreciated. In this area, lesions frequently appear just before or during puberty, and pruritus symptoms occasionally coincide with menstruation or pregnancy. Thus, a hormonal effect has been proposed.²⁹

A case report was found investigating PYL therapy in a Turkish patient with multiple vulvar syringomas. Two sessions of PYL were applied 4 weeks apart. After 4 weeks of follow-up, the lesion almost completely disappeared, and the complaint of itching was gone. The patient experienced mild erythema and edema, but the lesions healed within 7 days. The Fitzpatrick skin type was not specified in this patient.³⁰

Melasma

Melasma is a facial acquired hyperpigmented photoaging skin disorder affecting genetically predisposed individuals. Darker-skinned people with skin types IV to VI who have been exposed to strong ultraviolet radiation are at risk.³¹ Recent studies suggest that increased vascularity and factors secreted from vascular endothelial cells, such as stem cell factor and endothelin-1, can promote melanogenesis. Blood vessel-targeting laser treatment may therefore provide long-term suppression of pigmentation. A similar mechanism of action can be suspected for solar lentigo and ephelides.³²

A split-face trial reported PYL treatment for melasma in 82 patients. Both sides were treated topically with sunscreens and hydroquinone 4% cream, while the left side received PYL on top. Melasma lasted an average of 6.48 ± 4.93 years (between 1 and 25 years). According to Fitzpatrick skin types, they divided patients into 48 (58.5%) grade III and 34 (41.5%) grade IV groups. The family history of 40 (48.8%) patients was positive. According to Wood’s light examination, 64 (78%) patients had epidermal melasma, 15 (18.3%) had dermal type, and 3 (3.7%) had mixed type. After 6 months, the average melasma area and severity index score on the laser-treated side was statistically significantly lower than on the control side. Improvement in melasma did not significantly correlate with patient age, sex, skin photo type, family history, or the location or duration of the condition. The authors observed a significant correlation of outcome with the type of melasma, but the detailed information was missing. The study’s side effects included transient erythema in 5 (6.1%) patients and hyperpigmentation in 2 (2.4%) patients.³³

Post-acne erythema

Erythema caused by the release of inflammatory cytokines, dilating capillaries within the papillary dermis, and thinning of the epidermis is called post-acne erythema. Although it can last for months, the erythema typically goes away.³⁴

Sarac et al.,³⁵ analyzed a single-session PYL treatment in 40 patients with post-acne erythema and scarring (mean age 29.5 ± 8.16 years). The Fitzpatrick skin type was II in 12 patients (30%), III in 22 patients (55%), and IV in 6 patients (15%). A history of systemic isotretinoin use was present in half of the patients. PYL treatment was started immediately after stopping isotretinoin. Scarring was present in 26 patients (65%). Ten patients (25%) showed excellent (76–100% regression), 21 patients (52.5%) showed good (51–75% regression), and 9 patients (22.5%) showed moderate (26–50% regression) improvement. Considering the improvement rate of acne scars, moderate improvement was observed in 6 patients (23.1%) and mild improvement in 20 patients (76.9%). The patients experienced no adverse effects.³⁵

Another study reported PYL treatment in four post-acne erythema patients (mean age 22.3 ± 5.2 years). All patients had Fitzpatrick III skin type. On average, 1.75 ± 1 sessions were applied. A very good improvement was observed in all patients with a success rate of 78.7%.⁸

Becker’s nevus (BN)

BN belongs to benign cutaneous hamartomas. It appears as a hyperpigmented, occasionally hypertrichotic plaque or patch over the chest and shoulder. Histologically, BN exhibits rete ridge elongation and fusion, keratotic plugging, sebaceous hyperplasia, smooth muscle hyperplasia, and basal/suprabasal layer hyperpigmentation.³⁶ Dermoscopy reveals perifollicular hypopigmentation and vessels.³⁷ The target structures for PYL in this condition are dermal blood vessels, although a contribution of photo-thermolysis might be possible.

There is a case report on PYL treatment for BN in a 16-year-old female patient with Fitzpatrick III skin type. Two sessions of PYL treatment were given 4 weeks apart. The patient experiences only temporary, slight erythema and edema in the treatment area. There was a substantial decrease in hyperpigmentation.³⁸

Ephelides and lentigines

Common benign epidermal lesions include ephelides (freckles) and solar lentigines. Both are induced by sunlight. While ephelides are largely genetically determined, lentigines are induced by chronic sun exposure and are a sign of cutaneous photoaging.³⁹

A study was conducted on 50 patients presenting with ephelides (n = 25) and solar lentigines (n = 25) who were treated with PYL in Egypt (Fitzpatrick skin types II-IV). Patients received four laser sessions at 2-week intervals. There was a significant improvement in hyperpigmented lesions. Twenty-three patients (46%) showed marked improvement, 21 patients (42%) showed mild-to-moderate improvement. Moreover, 41 patients (82%) were either satisfied or very satisfied. Adverse events were mild and temporary and included pain, erythema, and hyperpigmentation, which resolved within 4 weeks after PYL treatment.⁴⁰

Onychomycosis

Onychomycosis is a common fungal disease caused mainly by dermatophytes. Medical treatment takes months, and relapse rates are high.⁴¹ Laser treatment is an alternative treatment option for onychomycosis, especially in the presence of contraindication for antifungal drugs. Lasers exert their therapeutic effects by selective photo-thermolysis of fungal elements.⁴²

PYL was compared to long-pulsed Neodymium-doped Yttrium Aluminum Garnet (Nd: YAG) 1064 nm laser (fluence: 35–45 J/cm, pulse duration of 20 ms) in 30 Egyptian patients (Fitzpatrick skin type II-IV) suffering from mycologically confirmed onychomycosis of fingernails (mean age 32.8 ± 11.9 years). The patients received six laser sessions 1 month apart at a fluence of 18 J/cm². The fluence was increased by 2 J/cm² up to 22 J/cm (PYL). The outcome was evaluated clinically using the onychomycosis severity index, standardized photographs, and mycological culture. Complete cure was observed in 7 (23.3%) patients treated with PYL and 4 patients (13.3%) with Nd: YAG laser (P = 0.015). PYL was safe and superior to Nd: YAG.⁴³